So now, Jan and I are in Masaka , under the supervision of local midwives. It has been busy and challenging. Over the last 2 and 1/2 days between Jan and I we have conducted 14 deliveries and resuscitated 6 babies who needed considerable help breathing. We've also prepared many women for c-sections and done our best to monitor the other labouring women, which at times it not realistic because there's so much else going on. Here is a snapshot of the crazy cases we've observed or participated in.
1. There was a woman pregnant for the 11th time with partial placenta previa (placenta partially covering the opening where the baby is born through) who was being prepared for a c-section when it was apparent that she had bulging membranes visible at the introitus and was going to deliver her baby. The membranes were ruptured and there were two loops of cord hanging out of her vagina. Major emergency! At this point the only option we had was to get her to push like stink and get her baby out. Thank God this woman pushed out several babies prior and was able to push this babe out within a few minutes. He was preterm (34 weeks) and needed some help breathing but considering what the potential consequences could have been, he did well. When we examined the placenta and membranes, we saw lots of vessels in the membranes and big succenturiate lobes throughout. Wow, how lucky was that baby!
2. A woman came in who had been assessed as being full-term and 8 cm dilated. The recommended plan was to rupture her membranes and deliver the baby. So when I went to assess her, the baby's head was too high to rupture the membranes, the head seemed very small for a term baby and I could not hear the fetal heart. I consulted with a midwives who suggested not rupturing the membranes and just waiting. An hour or so later Jan heard her waters break and as she was putting on gloves, she saw a small baby surf out with the waters. The woman had polyhydramnios (excess amniotic fluid) and so although her belly looked term the baby was actually only twenty some weeks old. She had a heart beat when she was born but she was clearly to young to breathe on her own. She died a few minutes later.
3. A woman rolls in on a stretcher, brought in from the village where she was trying to deliver. We uncovered her to find a another a large loop of cord and the baby's foot sticking out of the vagina! One of the midwives did a smooth breech extraction and the baby was thankfully fine. Miraculously, no resuscitation was needed.
4. One morning when we came in, there was a woman who was supposed to be prepared for a c-section because her labour was obstructed. Of course everything takes time here with everything else going on, so by the time we got around to preparing her another vaginal exam was and it was decided the baby's head had come down enough and she would deliver vaginally. No fetal heart could be found on the baby. I put on gloves to do the delivery and the baby's head came shortly thereafter followed by thick, dark, pea-soupy meconium. Jan and I lost hope of this baby being alive when we saw that. The delivery of the baby's shoulders took a few shoulder dystocia manoeuvres to get out, likely because the baby had no tone. Unfortunately when the baby was born, we confirmed what we feared, that there in fact was no heart beat.
5. A woman had come in from her village with an obstructed labour. The doctor decided to try a vacuum in the operating theatre so that if it failed a c-section could be done. The vacuum failed and so a c-section was done. The baby died minutes after delivery.
6. I followed a woman who was expecting her first baby all day Tuesday. She spoke great English and so throughout the day we had made a good connection. She needed to be augmented with oxytocin as her contractions were infrequent. Her baby's heartbeat was strong throughout her labour, but unfortunately when we ruptured her membranes an hour or so before she delivered, they were dark brown--meconium. When her baby was born, Jan and I resuscitated her for 12 minutes before she breathed on her own. Her breathing remained laboured. Although she received medication and dextrose before we left, she died around midnight. This was the first time I had cared for a mother in labour whose baby dies shortly thereafter. It was really sad and difficult to process.
7. The same day I learned the baby died, there were 2 more babies who needed significant resuscitation. With the first, the power went out just as we were bringing the baby to the nursery so we could continue the resuscitation under a lamp, so the baby would be warmer. Then it was decided the baby needed oxygen so Jan and I ran around the hospital compound from the emergency to paediatrics to the operating theatre--Jan holding the baby and me walking briskly beside her continuing to breathe for the baby with the bag and mask. We were not successful in getting oxygen for the baby as as the oxygen system here relies on electricity and the generator in the OR wasn't working either. No oxygen for this baby nor the next baby who needed resuscitation. We don't know if these babies made it or not. We'll know when we return to the hospital tomorrow.
8. The same day at the 2 above resuscitations, another woman rolls in on a stretcher. She delivered a baby in her village and then the placenta wouldn't come. She bled a lot and was transferred in. When she arrived the midwives determined that the baby she delivered was one of 2 babies--she was having twins. When she arrived, the placenta was partly out of the vagina and the 2nd twin was yet to be born. She no longer had effective contractions so needed to have a line of oxytocin put up. It took a while to deliver the second babe who came out sunny-side up/OP with no heartbeat. The mother's placenta had abrupted.
So that's just a snip-it of the last week. It's intense and it's hard to keep straight what happens when. At home if we were faced with any one of these cases, we would have the time and space to process what happened. But here, it's non-stop and you have to pick yourself up and move on to the next woman and/or baby who need care. There are only 2 working days left for us and then we are making our way back to Kampala this weekend and catching a flight home Monday. It has been an incredible though challenging learning experience. However I have no regrets doing a placement here. I have seen more than I could have imagined, and, in these 6 weeks I have almost done what would be a year's worth of catches for a midwife practicing in BC. Looking forward to connecting with some of you upon my return home.
Lydia
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UBC Students for Global Citizenship
The Midwifery Education Program at the University of British Columbia (UBC) has created a global midwifery placement option for students. This year, two midwifery faculty members and a family physician will accompany the students for part of their practicum and then local midwives, nurses and physicians will continue supervision.
For the past 4 years, UBC Midwifery students have participated in this 6 - 8 week global placement at the end of the 3rd year of their midwifery education. This year Midwifery is pleased to have colleagues from Medicine and Nursing join us.
In these placements students attend births and experience the ways that health care workers deal with normal and difficult births in a low-resource setting. These skills are especially relevant to student accouchers as they prepare to respond to the critical shortage of skilled maternity providers in rural and remote areas of British Columbia. In exchange, students and faculty share ways of practice taught at UBC with the global midwifery community.
Students return energized by their global experience and have a deeper understanding about women’s health issues, women’s rights and birthing practices, and with new friendships across borders.
Uganda. Maternal mortality is high in rural Uganda. Over 510 per 100,000 women die in childbirth. There are few trained attendants to assist women in childbirth, and transportation problems as well as social customs prevent many women from attending health centres and hospitals for deliveries. Those who attend hospitals for delivery often have risk factors and complications rarely seen in Canadian maternity practice.
Students and faculty take donations of gloves, delivery instruments, medication to prevent and treat hemorrhage, and academic articles and books on continuing education topics. Midwifery faculty work in collaboration with local staff to present continuing education topics on maternity subjects requested by the local nurse-midwife managers and medical directors. This year we raised funds to buy supplies for maternity wards and to bring a Ugandan Midwife to B.C. for an educational visit this past April.
For the past 4 years, UBC Midwifery students have participated in this 6 - 8 week global placement at the end of the 3rd year of their midwifery education. This year Midwifery is pleased to have colleagues from Medicine and Nursing join us.
In these placements students attend births and experience the ways that health care workers deal with normal and difficult births in a low-resource setting. These skills are especially relevant to student accouchers as they prepare to respond to the critical shortage of skilled maternity providers in rural and remote areas of British Columbia. In exchange, students and faculty share ways of practice taught at UBC with the global midwifery community.
Students return energized by their global experience and have a deeper understanding about women’s health issues, women’s rights and birthing practices, and with new friendships across borders.
Uganda. Maternal mortality is high in rural Uganda. Over 510 per 100,000 women die in childbirth. There are few trained attendants to assist women in childbirth, and transportation problems as well as social customs prevent many women from attending health centres and hospitals for deliveries. Those who attend hospitals for delivery often have risk factors and complications rarely seen in Canadian maternity practice.
Students and faculty take donations of gloves, delivery instruments, medication to prevent and treat hemorrhage, and academic articles and books on continuing education topics. Midwifery faculty work in collaboration with local staff to present continuing education topics on maternity subjects requested by the local nurse-midwife managers and medical directors. This year we raised funds to buy supplies for maternity wards and to bring a Ugandan Midwife to B.C. for an educational visit this past April.
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